Adherence to Evidence Based Medicine Bunions Matt Rogers, Transformation Programme Manager Enfield Clinical Commissioning Group MR v01

Bunions – Approach Performed a review across a number of CCGs in order to assess the variation in provision of access between Enfield, North Central London and other CCGs as follows: North West London CCG North East Essex CCG South East London CCG Cambridgeshire CCG Berkshire CCG Others Collated evidence on eligibility criteria Data analysis including: Activity & Spend Trend Analysis Benchmarked Enfield CCG data against North East London CCGs, standardised per 1,000 population

Activity 2015/16 62 Cost 2015/16 £173,631 Bunions – Activity & Spend ENFIELD CCG Data Activity 2015/16 62 Cost 2015/16 £173,631

Bunions – Activity & Spend – Trend Analysis

Bunions – Benchmarking Spend Standardised Per 1,000 Population   Enfield CCG NCL CCGs BHR CCGs WELC CCGs Bunions (Hallux valgus) surgery £151.3 £105.9 £97.1 £72.8

ENFIELD NCL Other CCGs Bunions– Policy/Criteria Comparison NICE Guidance states: In hallux valgus (Bunion) the big toe is deviated towards the other toes and a bony protrusion (a bunion) is formed by medial deviation of the first metatarsal phalangeal joint. There may be damage to the skin over the bunion, pain when walking, cosmetic concerns and difficulty with footwear. 2.1.2 Conservative treatment may include footwear modification, and use of insoles or toe spacers. Common surgical treatment options involve different types of first metatarsal osteotomy. 2.2 Outline of the procedure 2.2.1 Surgical correction of hallux valgus using minimal access techniques is carried out with the patient under local or general anaesthesia and with X-ray or endoscopic monitoring. One or more small incisions are made close to the hallux metatarsophalangeal joint. The bunion is removed and the metatarsal is divided surgically. The bone fragments may be stabilised using plates, screws or wires. A dressing or plaster may be used to support the foot in the corrected position until the divided bone heals ENFIELD Organisation Eligibility Criteria Exists Enfield CCG N Enfield CCG has not adopted a policy / criteria for elective Bunions surgery NCL Other CCGs Organisation Eligibility Criteria Exists BARNET CCG N HARINGEY CCG ISLINGTON CCG CAMDEN CCG Organisation Eligibility Criteria Exists Dorset CCG Y Bristol CCG Gloucestershire CCG Basildon & Brentwood, Southend, Castle Point & Rochford, and Thurrock CCGs